J7311 — Injection, fluocinolone acetonide, intravitreal implant (retisert), 0.01 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of the specific covered diagnosis that matches one of the policy's covered indications (use of the ICD-10 codes listed in the policy is implied).
- For Iluvien: documentation of prior course(s) of corticosteroid treatment (e.g., dates, agent, route) and documentation that the member did not have a clinically significant rise in intraocular pressure following that corticosteroid course.
- For Dextenza: documentation that the product was prescribed by or in consultation with an ophthalmologist (prescription or consultation note).
- Documentation of laterality (which eye), and that the dose does not exceed one insert/implant per eye.
Key Coverage Criteria
- Ozurdex (dexamethasone intravitreal implant): Diabetic macular edema (DME).
- Retisert (fluocinolone acetonide intravitreal implant): Chronic non-infectious uveitis affecting the posterior segment of the eye.
- Yutiq (fluocinolone acetonide intravitreal implant): Chronic non-infectious uveitis affecting the posterior segment of the eye.
- Dextenza (dexamethasone ophthalmic insert): Ocular inflammation and pain following ophthalmic surgery.
- Dextenza (dexamethasone ophthalmic insert): Ocular itching associated with allergic conjunctivitis.
- Iluvien (fluocinolone acetonide intravitreal implant): Chronic non-infectious uveitis affecting the posterior segment of the eye.
4 Active Policies
AETNA-CPB-0719 — Fluocinolone Acetonide Intra-vitreal Implant (Retisert, Yutiq and Iluvien)
UHC-POL-intravitreal-corticosteroid-implants — Intracanalicular and Intravitreal Corticosteroid Implants
UMR-POL-UMR-intravitreal-corticosteroid-implants — Intracanalicular and Intravitreal Corticosteroid Implants
SUREST-POL-SUREST-intravitreal-corticosteroid-implants — Intracanalicular and Intravitreal Corticosteroid Implants
Related Codes
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